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When is it Proper to Bill Nurse Visits using 99211

Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
2021-09-28

When vaccines or injections are given in the office, coding can often get confusing; for example, is it correct to report a nurse visit using 99211 and an E/M office visit reporting 99202 ‑ 99215 and include injection fees with the vaccine product? In addition, the reporting of evaluation and management (E/M) during the same visit where vaccines are administered is not always understood. The answer depends on whether the provider performs a medically necessary and significant, separately identifiable E/M visit, in addition to the immunization administration.

CMS states, when a separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to drug administration services, you should report the appropriate E/M CPT code reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.

It is incorrect to bill a 99211 when the provider provides an E/M service that meets a higher complexity level than CPT code 99211, you must bill the higher complexity, and you cannot bill for two services in one day. 

Charging for Nurse Visits

There are times when it is appropriate to report for a nurse visit using CPT code 99211. The Incident-to rule applies when reporting this code, and services provided must be documented as medically necessary services, including the clinical history, clinical exam, making a clinical decision, and physician supervision. 

  • NOTE: A nurse visit is not paid if billed with a drug administration service such as chemotherapy or non-chemotherapy drug infusion code, including therapeutic or diagnostic injection codes. The reasoning is because diagnostic IV infusion or injection services typically require direct physician supervision, and using 99211 is reported by qualified health care professionals other than physicians.

When reporting CPT codes 90782, 90783, 90784, or 90788, CPT code 99211 cannot be reported. In addition, it is improper billing to report a visit solely for an injection that meets the definition of the injection codes. 

When the only reason for the visit is for the patient to receive an injection, payment may be made only for the injection (if it is covered). An office visit using 99211 would not be warranted where the services rendered did not constitute a regular office visit.

Unlike other E/M codes 99202-9920599212-99215, time alone cannot be used when reporting 99211 when selecting the appropriate code level for E/M services. Effective January 1, 2021, time was removed as an available code-selection criterion. The typical time spent on this code is five minutes.  

Other visits billed with 99211

Several other visits may be reported using 99211, and nurses are not the only staff that can report this code; medical Assistants and technicians are also included under non-physician.  

Covid-19 Testing

According to CMS; Physician offices can use CPT code 99211 when office clinical staff furnish assessment of symptoms and specimen collection for Covid-19 incident to the billing professionals services for both new and established patients. When the specimen collection is performed as part of another service or procedure, such as a higher-level visit furnished by the billing practitioner, that higher-level visit code should be billed. The specimen collection would not be separately payable.

Examples from CMS

The following are examples of when CPT 99211 might be used:

  • Office visit for an established patient for blood pressure check and medication monitoring and advice. History, blood pressure recording, medications, and advice are documented, and the record establishes the necessity for the patient's visit.
  • Office visit for an established patient for return to work certificate and advice (if allowed to be by other than the physician). Exam and recommendation are noted, and the Return to Work Certificate is completed, copied, and placed in the record.
  • Office visit for an established patient on regular immunotherapy who developed wheezing, rash, and swollen arm after the last injection. Possible dose adjustments are discussed with the physician, and an injection is given. History, exam, dosage, and follow-up instructions are recorded.
  • Office visit for an established patient's periodic methotrexate injection. Monitoring Lab tests, query signs and symptoms, obtain vital signs, repeat testing, and injection advised. All this information is recorded and reviewed by the physician. (Note that in this circumstance, if 99211 is billed, the injection code is not separately billable). An office visit for an established patient with a new or concerning bruise is checked by the nurse (whether or not the patient is taking anticoagulants), and the patient is advised on how to care for the bruise and what to be concerned about, and, if on anticoagulants, continuing or changing current dosage is advised. History, exam, dosage, and instructions are recorded and reviewed by the physician.
  • Office visit for an established patient with atrial fibrillation who is taking anticoagulants and having no complaints. The patient is queried by the nurse, vital signs are obtained, the patient is observed for bruises and other problems, the prothrombin time is obtained, the physician is advised of prothrombin time and medication dose, and medication is continued at present dose with follow up prothrombin time in one month recommended. History, vital signs, exam, prothrombin time, INR, dosage, physician's decision, and follow-up instructions are recorded.

References